Safe injection, infusion and medication-vial practices at a tertiary care centre: a quality improvement initiative

Introduction: There is a risk of transmission of viruses and microbial pathogens during routine health care procedures due to improper injection, infusion, and medication-vial practices. Unsafe practices lead to outbreaks of infection resulting in unacceptable and devastating events in patients. The present study was undertaken to assess the compliance of nurses with safe injection and infusion practices in our hospital and to identify staff education requirements in relation to the safe-injection and infusion practices policy. Methods: Baseline data were collected and high risk areas were identified on this basis, a quality improvement project was implemented by infection control team. FOCUS PDCA methodology was used to conduct the improvement process. The study was performed from March to September 2021. An audit checklist based on the CDC guidelines was used for monitoring compliance with safe injection and infusion practices. Results: Poor compliance with safe injection and infusion practices in few clinical areas at baseline. During the pre-intervention period, non-compliance was mainly seen with the following elements: aseptic technique (79%), rubber septum disinfected with alcohol (66%), labelling of all IV lines and medications with date and time (83%), compliance with multidose-vial policy (77%), use of multidose vials for single patient (84%), safe disposal of sharps (84%), using trays instead of clothing/pockets to carry medications (81%). There was significant improvement in compliance with the following elements of safe injection and infusion practices in the post-intervention period: aseptic technique (94%), rubber septum disinfected with alcohol (83%), compliance with multidose-vial policy (96%), use of multidose vials for single patient only (98%), safe disposal of sharps (96%). Conclusion: Adherence to safe injection and infusion practices is very important to prevent outbreaks of infection in health care settings.


Introduction
The World Health Organization (WHO) defines a safe injection as one which does not harm the recipient, does not expose the provider to avoidable risk, and does not result in waste that is dangerous for the community. It is expected that this evidence-based policy guidance will additionally contribute to preventing the re-use of syringes on patients, thus decreasing the rate of needle-stick injuries in health-care workers (HCWs) related to injection procedures. They are part of standard precautions which help in the prevention of transmission of infections due to unsafe injections [1]. Injectable medicines are commonly used in health-care settings for the diagnosis, treatment and prevention of various illnesses. The Centers for Disease Control and Prevention (CDC) evidence-based Standard Precautions guideline on safe administration includes adherence to practices such as 1. not administering medications from the same syringe to more than one patient, 2. not entering a vial with a used syringe or needle, 3. administering medications from single-dose vials to multiple patients, 4. maintaining aseptic technique at all times, 5. disposing properly of used injection equipment, 6. not using bags of intravenous solution as a common source of supply for more than one patient, 7. not keeping multi-dose vials in the immediate patient treatment area [2], [3].  [4]. The estimated number of injections per person per year is 3.4 (range 1.7-11.3) and the proportion of unsafe injections is 39% (range 1.2-75%) [5]. In some areas of South East Asia including India, the WHO South East Asian (including India), the estimate for unsafe injection is greater than 75%. It has been estimated that in India, around three billion injections are administered annually, with 1.89 billion of them being unsafe [6]. There is risk of transmission of blood-borne viruses and microbial pathogens to patients during routine health care procedures due to improper injection, infusion and medication-vial practices. These unsafe practices are unacceptable and cause devastating events in patients.
With this background, this study was conducted to assess the compliance of nurses with hospital policy on safe injection and infusion practices and identify staff education requirements in relation to the policy.

Study design
This is an observational study.

Study setting
The study was conducted at a tertiary care hospital in Hyderabad, Telangana, India, from March 2021 to September 2021. This hospital is an 800-bed multispecialty facility, accredited by NABH and JCI (Joint Commission International) and has comprehensive institutional policies for infection prevention and control as well as antimicrobial stewardship. The setting where the study was conducted included nursing staff of intensive care units, emergency departments, and inpatient wards. The process flow chart showed that protocols on safe injection and infusion practices were made available at respective nursing stations. Staff were trained in these by the infection control team, but there were gaps in implementation of policy by nursing staff in all clinical areas. A fishbone analysis ( Figure 1) of the problem showed that there were no clean utilities in a few nursing stations for medication preparation. Hence, the nurses were preparing the medications at bedside. Some of the reasons for noncompliance were lack of knowledge, shortage of personnel and negligence. Inappropriate disposal of waste was due to non-availability of ampoule cutters and lack of puncture-proof containers at the point of use. The quality improvement team decided to instruct the staff on the importance of safe injection and infusion practices, which is one component of standard precautions. It was planned to identify areas where clean utilities were not available.

Phases of the study
The study included phase 1, the pre-intervention phase from March to May 2021, and phase 2, the interventional phase from April to August 2021. We performed the following activities during phase 1: • Sample size and justification: Sample size was calculated as 152 by using a sample size calculator. This means 152 or more measurements/surveys are needed to have a confidence level of 95% that the real value is within ±5% of the measured or surveyed value. • Sample selection method: During the study period, multiple structured observations were carried out by the infection control nurses and link nurses, who visited the clinical departments of the hospital to observe safe injection and infusion practices of the nurses by using a checklist to obtain accurate information and review compliance with safe injection practices. • Tools of study: A pre-designed data collection checklist adopted and modified from the CDC guideline of the revised injection safety assessment tool was used as a tool in this study ( Figure 2). Safe injection and infusion practices is one of our hospital infection control quality indicators, and data is collected by infection control nurses using an audit checklist. Non-compliance with any of the components in the checklist was taken as 100% non-compliance. The data is compiled, analyzed and presented at the hospital infection control committee meeting every month (Table 1). Investigators visited the study settings and observed the procedure of safe injection and infusion practices during their daily surveillance. These visits were not announced ahead of time. • Baseline measures: The data compiled revealed that the compliance with safe injection and infusion prac- During phase 2, the following activities were realized: •

Results
During analysis of the compiled data, non-compliance with even one element in the audit checklist was considered as 100% non-compliance, because unsafe practices are unacceptable and may cause outbreaks leading to devastating events in patients. The data compiled during the pre-intervention phase revealed some high-risk areas with poor compliance with safe injection and infusion practices (Table 2). Table 2: Pre-and post-interventional non-compliance rates in risk areas Figure 2: Revised injection safety assessment tool (Tool for data collection).xx in the 7 th cell, left column, change "Medication administration tubing's" to "Medication administration: tubings"; in the last cell, left column, change "Transporting" to "Do not transport"  Compliance percentage with various elements of safe injection and infusion practices was calculated. Noncompliance was mainly seen with the following elements: aseptic technique (79%), rubber septum disinfected with alcohol (66%), labelling of all IV lines and medications with date and time (83%), compliance with multidose-vial policy (77%), use of multidose vials for single patient (84%), safe disposal of sharps (84%), using trays instead of carrying medications in clothing/pockets (81%) (Figure 3). An improvement plan was made and actions were executed within the time frames given in Table 3. Re-auditing was conducted by infection control nurses following implementation of interventional strategies. Data analysis showed a significant decrease in noncompliance with safe injection and infusion practices ( Table 4). Table 4: Pre-and post-interventional non-compliance rates Significant improvement was found in compliance with the following elements of safe injection and infusion practices in the post-intervention period: aseptic technique (94%), rubber septum disinfected with alcohol (83%), compliance with multidose-vial policy (96%), use of multidose vials for single patient (98%), safe disposal of sharps (96%) (Figure 4). There was only marginal improvement in labelling of IV lines and medications. The quality improvement project was presented at the infection control committee meeting for approval. The quality improvement team achieved its aim and is sustaining it to date.

Discussion
With this quality improvement project, we identified all clinical areas requiring clean utilities, which is a key component for implementing safe injection and infusion practices. In a study by Rajneesh et al. [7], similar unsafe injection practices were observed, such as not preparing injections on a clean workable tray (35%), not removing needles from the cap of multidose vials (40%), recapping needles (4%), not following hand hygiene (33%) and not using clean barriers (87.5%) to protect fingers while breaking glass ampoules in the study hospital.
Many nursing staff had suffered needlestick injuries due to poor compliance with safe disposal of sharps and nonavailability of PPCs at the point use. The incidence of needlestick injuries decreased following training of staff on safe disposal of sharps [8], [9], [10]. The importance of adherence to the aseptic technique was recognised by the nurses after taking up this project [11], [12]. A study by Paul et al. [12] at a tertiary care hospital in West Bengal showed similar results. Only 12.5% of study subjects performed hand hygiene before giving injections and only 3.7% of them used gloves during injection. Our compliance rate was higher compared to Paul's study and similar to studies in Egypt, Nepal and West Bengal [13], [14], [15]. Our quality improvement project allowed the team to improve patient care in all clinical areas, including very busy areas such as the emergency department and intensive care units. The success was also dependent on good communication and coordination between the infection control team and the nursing department. The team plans to carry this process forward by continuous training and monitoring staff practices.

Conclusions
Adherence to safe injection and infusion practices is very important to prevent outbreaks of infection in health-care settings. This quality improvement project helped us identify gaps in our current practices and make significant improvement for better patient care. Continuous healthcare professional training on infection control and safe injection and infusion practices should be encouraged. Frequent infection control auditing is mandatory to ensure compliance with safe injection and infusion practices.

Notes Competing interests
The authors declare that they have no competing interests.